EMS Staff Roster
Complete the information below to be added to our on-call list.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Upload your Headshot or Profile Photo
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Provide a Brief Description of Your Professional Experience:
Highest Level of Medical License/Certification
MD or DO
NP
PA
RN
Paramedic
LVN
AEMT
EMT-B
CNA
EMR
Issuing State of License/Certification
License/Certification Number
Certification Expiration Date
-
Month
-
Day
Year
Date
List all other states in which you are licensed to practice:
List Any Additional Medical Certifications:
Upload a Copy of Your Medical Certificates and/or Licenses:
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Upload your BLS/CPR/AED Certificate:
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Upload your kit inventory
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Upload a copy of your medical malpractice insurance
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List any languages (other than English) that you are fluent in:
Which positions are you interested in?
Set Medic
Event Medic
Disaster Response/Volunteer Work
Are you part of the Local 80 Union?
Yes
No
On Permit
Are you willing to travel?
No (Los Angeles Area Only)
Yes (CA and surrounding states)
Yes (US)
Yes (International)
Shirt Size
Referral Name:
How did you hear about us?
Is there anything else you would like to tell us?
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